When it comes to true Obsessive Compulsive Disorder (OCD), not all therapy is the same. The gold standard of psychotherapy for the treatment of OCD is Exposure & Response Prevention (EX/RP) and it is essential to find someone who is trained to do it well. With OCD, alternative models of therapy can actually cause harm. Complicating matters further, clinicians who are unfamiliar with the multiple varieties of OCD often have difficulty identifying the disorder due to lack of training and experience. As seasoned OCD therapists know, patients do not always present as a person who washes their hands repeatedly or lines up shoes with a measuring tape.
OCD can manifest in a variety of different ways, but always includes thoughts or urges that an individual has attempted to control without success. There are several different themes that obsessions can reflect and few people are aware of all of the variety that exists. Some examples include hoarding, fears of contamination, existential types, homosexual/heterosexual fears, repugnant obsessions, and more. It seems that if it is something that can be thought, there is an OCD version of it. One of the most difficult types of OCD to diagnose is a variety called “Pure-O.” This is basically OCD that involves mental gymnastics instead of physical ones. For more about Pure-O: https://www.intrusivethoughts.org/
What it looks like
There are multiple formal instruments that can assist with diagnosing OCD, but the real key is finding someone who knows the subtle way it can hide and how to listen (and watch) for the signs of OCD in an evaluation. The commonality for all OCD is that there is an avoidance of certain internal experiences—anyone who has OCD has at least one idea, thought, urge, image, sensation, or emotion that they work very hard not to have. They work very hard trying not to have the thought, image, idea, etc. It is exhausting and it takes up a great deal of their mental energy and actual time. The method that they use to stop the process determines what their type of OCD actually looks like. For example, they may have an image of themselves becoming ill and the work they put into it is disinfecting everything, researching illnesses, and avoiding touching people. Another person may have the same fear of becoming ill, but the work they put into it is praying hundreds of times a day, getting tested for illnesses, and checking their blood pressure, heart rate, and temperature daily. It is common for individuals to be completely unaware that they have OCD. Instead, they think of themselves as chronic worry warts, as “hypochondriacs,” or as a “bad” person who is able to fool everyone around them.
Treating OCD the wrong way can lead to disaster. EX/RP involves identifying the fear and allowing it to be fully present without the individual “doing their usual.” If “their usual” is washing, then they would get dirty instead. If “their usual” is arranging things perfectly, then they would mess them up. If “their usual” is to reassure themselves that they aren’t actually sick, then they would imagine, in excruciating detail, the specifics of having a terminal illness and their own impending funeral. This may sound cruel, but in actuality, the most harmful thing that a treatment provider can do to a person with OCD is reinforce their compulsion by encouraging them to do it, or avoiding it alongside them. Avoidance only leads to worsening of symptoms.
As an example, a young woman experienced thoughts of harming her child and her “usual” response to the thoughts was to overprotect her child. She hid knives, avoided her child, and made sure she was never alone with her. She was terrified of hurting the baby but had no actual desire to do so, in fact, she spent the majority of her waking hours trying to figure out how to keep the infant safe. When she finally summoned the courage to seek mental health treatment, instead of identifying the issue for what it was and providing her with assistance, her child was summarily removed from her custody. Thankfully, she located a treatment provider who was familiar with EX/RP who was able to coach her through a series of imaginary scenarios in which she killed the baby. Read the last sentence again. What healed her in the end was a combination of imagining horrific scenes involving her stabbing her child along with holding a knife in her hand while her daughter lay beside her. She, nor her thoughts, were dangerous; but she was led to believe differently by the very people who were supposed to help. Imaginal exposure to the idea that was feared (killing her child) combined with exposure to the avoided objects (knife and daughter) led to the alleviation of symptoms and this mother and daughter could go on with their lives without the burden of fear and shame.
Accurate diagnosis and informed treatment are key. Don’t compromise when it comes to choosing a therapy or a therapist. Although “supportive therapy” may feel good and EX/RP may be uncomfortable, when it comes to the treatment of OCD, it’s like your grandmother used to say, “if it hurts, that means it’s working!”